Mv104

SIGN YOUR REPORT OF MOTOR VEHICLE ACCIDENT (MV-104 Form)

Date

Print Name of Driver (or Represetnative*) of Vehicle 1
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Signature of Driver (or Representative*) of Vehicle 1
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* A representative may sign for the driver if the driver is unable to sign because of injury or death. If you are signing as the driver’s representative, check the box that describes why the driver cannot sign below.

Injury Death

Check the “Rush” box below if your license is suspended for failure to report this accident:

RUSH - DRIVER OF VEHICLE 1 - LICENSE SUSPENDED FOR FAILURE TO REPORT

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